Information Collection

SAMHSA Data Security Requirements for Accessing Confidential Data

IC 261703 under ICR 202308-0930-001 · OMB 0930-0396.

Documents and Forms

Document Name Document Type
Form Designated Agent F SAMHSA Data Security Requirements for Accessing Confidential Data Form and Instruction
Designated Agent F Designated Agent Form SAMHSA-Designated-Agent-Form.pdf Form and Instruction
Designated Agent F Designated Agent Form SAMHSA-Designated-Agent-Form.pdf Form and Instruction
Data Use Agreement Data Use Agreement Form Access-Agreement-20211101-Fillable.pdf Form and Instruction
Data Use Agreement Data Use Agreement Form Access-Agreement-20211101-Fillable.pdf Form and Instruction
SAMHSA RDC Student SAMHSA RDC Student Data User Acknowledgment Form Student-Advisor-Agreement_20221213_508.pdf Form and Instruction
SAMHSA RDC Student SAMHSA RDC Student Data User Acknowledgment Form Student-Advisor-Agreement_20221213_508.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SAMHSA Data Security Requirements for Accessing Confidential Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Designated Agent Form	Designated Agent Form	SAMHSA-Designated-Agent-Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	Data Use Agreement Form	Data Use Agreement Form	Access-Agreement-20211101-Fillable.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	SAMHSA RDC Student Data User Acknowledgment Form	SAMHSA RDC Student Data User Acknowledgment Form	Student-Advisor-Agreement_20221213_508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Privacy Act of 1974 (Title 5 United States Code [U.S.C.] 552a)	FR Citation: 75 FR 28264

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.